Oral Lichen Planus Overview

Oral Lichen Planus: Overview

• Oral lichen planus (OLP) is an inflammatory mucocutaneous condition.
• It is chronic and potentially lifelong.
• The cause of OLP is unknown
• It is characterized by remissions and exacerbations.
• It mainly affects middle-aged adults over 40.
• OLP is more common in women.

Lichen Planus: Clinical Presentation

• Skin: Causes pruritic, violaceous papules and plaques. Common locations include wrists, ankles, legs, and back.
• Scalp: Causes pruritic papules and atrophic scarring accompanied by patchy hair loss.
• Nails: Presents with subungual hyperkeratosis and anonychia (loss of the nail).
• Mucosa (OLP): Affects oral mucosa most frequently (approximately 60%). Also affects genital mucosa less often

Oral Lichen Planus: Additional Details

• Aetiology: No identifiable cause exists.
• OLP vs Oral Lichenoid Lesions: Certain lesions resemble OLP clinically and histopathologically; however, some have an identifiable etiology.
• Epidemiology:
  • The prevalence of Lichen Planus is less than 1%.
  • Oral Lichen Planus prevalence is 1-2%.
  • No racial predilection is noted.
  • The male to female ratio is 1:4.
  • Age typically ranges from 40-70 years.

Pathogenesis

• Unknown etiology: The exact cause of OLP remains unknown.
• T-cell mediated disease: An immune response seems to be involved, specifically involving T-cells
• Altered immune response: The immune response results in apoptosis (programmed cell death) of keratinocytes in the basal layer.
• Predisposing Factors (potential causes):

  • Psychological factors include anxiety and depression.

  • Viral infection (Hepatitis C virus).

  • Dental restoration materials.

  • Certain medications (drugs)

  • Note: The importance of psychological factors in the development of OLP is debated.

Oral Lichen Planus: Clinical Features

• Skin/Mucosal involvement: OLP may also affect skin in 15% of cases.
• Lesions: Often present as white or grey streaks that form linear or reticular patterns.
• Location: Common locations include buccal mucosa, tongue, gingiva, and lower lip. Less common areas include palate, floor of the mouth, and upper lip. A study of 205 patients showed 89.7% of them had buccal mucosa involvement, 50.2% had tongue involvement, and 27.3% had gingiva involvement.
• Clinical Forms:
  • Reticular: Most common, characterized by fine, overlapping, white striae (Wickham striae). Usually asymptomatic.
  • Atrophic: Diffuse red lesions with white striae surrounded by a red rim. Often painful.
  • Erosive: Most significant form; characterized by ulcerations (potentially covered by a fibrin plaque or a pseudomembrane).
  • Desquamative gingivitis: Affects the gingiva of roughly 10% of patients with OLP, with erythematous or ulcerated areas and associated whitish areas.

Diagnosis

• Clinical examination: Assessing the appearance of lesions.
• Histopathological examination: Microscopic examination of tissues.
• Diagnosis is considered doubtful: if lesions are unilateral, isolated, or if no bilateral involvement of buccal mucosa.

Histopathological Aspects

• Liquefactive degeneration: Characteristic finding in basal layer (hydropic degeneration).
• Inflammatory infiltrate: Dense band-like infiltrate of T lymphocytes.
• Epithelial maturation: Normal in most cases.
• Hyperkeratosis: (orthokeratosis or parakeratosis)

Direct Immunofluorescence

• Fibrinogen deposits, in an irregular pattern, are observed in the basement membrane.

Differential Diagnosis

• The diagnosis depends on the morphology of the lesions. Possible conditions to rule out include: cheek biting, leukoplakia, white sponge nevus, candidiasis, aphthae, pemphigus vulgaris, and pemphigoid.

Malignization

• The potential for OLP to progress to malignancy is controversial.
• Studies vary in the frequency of malignancy, ranging from 0 to 5.3% in follow-up studies of 6 months to 20 years.
• The challenge in studying malignancy in OLP is the lack of objective and unanimous diagnostic criteria

Treatment

• Goal: Primarily to relieve symptoms and minimize disease impact.
• The treatment approach is individualized.
• No single treatment is effective in all cases: Due to the unknown etiology
• Oral hygiene: Essential, especially with gingival involvement. Polished teeth, fillings, and dentures should be addressed.
• Exclusively reticular lesions: Often don't require treatment (asymptomatic).
• Treatment focuses on::
  • Atrophić lesions
  • Erosive lesions
  • Symptomatic lesions
• Medical Treatment: Primarily corticosteroids (topical, intralesional, or systemic) and tacrolimus mouth rinse.

Treatment Options: Localized Erosive OLP

• Perilesional steroid injections (Triamcinolone Depot 10-20 mg)

Treatment Options: Generalized Atrophic/Erosive OLP

• Systemic corticosteroids (Prednisone 30-60 mg/day)
• Tacrolimus mouth rinse (0.1mg/100ml distilled water, 4 times/day for 6 months. )

Topical Ointments/Mouthwashes (for lesions)

• Triamcinolone acetonide 0.1%
• Fluocinolone acetonide 0.05%
• Clobetasol 0.05% (applied 2-4 times daily)

Topical Antifungal Therapy (especially if infection occurs)

• Topical antimycotics (often needed given the immunosuppressive therapies often used).

Specific Considerations in Treatment (Oral Lichenoid Reactions-Possible to be related to Dental Materials/Medications)

• Dental Materials: Removal of dental amalgams or other materials if closely related, especially if unilateral involvement is present
• Drugs: Removal or changing problematic drugs (caution as changes can sometimes take months to see improvement), if needed due to the nature and severity of the condition.

Additional Points

• A flow chart provides a visual summary to the different treatment strategies for OLP.

This quiz explores Oral Lichen Planus (OLP), an inflammatory condition affecting the oral mucosa. Learn about its clinical presentation, common demographics, and distinguishing features. Understand the key characteristics and potential impacts of OLP on patients.